Leonid V. Klimov

Ischemic stroke remains a major medical, social, and economic concern due to high disability rates and substantial treatment and rehabilitation costs. Reperfusion therapy (thrombolysis and thrombectomy) is one of the most effective therapeutic options, considerably reducing mortality and disability rates. However, 2%–7% of thrombolysis cases are associated with symptomatic hemorrhagic transformation, which causes clinical deterioration and limits rehabilitation. Hemorrhagic transformation is caused by a disruption of the blood-brain barrier, which has a protective function and is characterized by selective permeability. The blood-brain barrier is formed by endothelial cells, astrocytes, pericytes, neurons, and the extracellular matrix. Tight junction proteins in endothelial cells are essential for maintaining blood-brain barrier integrity. In ischemic stroke, neuroinflammatory mechanisms are activated, leading to the degradation of tight junction proteins and extracellular matrix components, which results in increased blood-brain barrier permeability and dysfunction. Reperfusion therapy may exacerbate blood-brain barrier injury due to reactive hyperemia caused by impaired cerebral autoregulation. Existing imaging markers of hemorrhagic transformation (infarct volume, hyper dense middle cerebral artery sign on computed tomography, severity of leukoaraiosis, presence and extent of collateral circulation, etc.) are not always easily accessible or interpretable. Therefore, there is ongoing interest in identifying simple and reliable biomarkers that can serve as laboratory indicators. These include routine parameters (serum glucose, urinary albumin, lipid profile parameters, thromboelastography indices, B-type natriuretic peptide) as well as more specific markers such as matrix metalloproteinases, tight junction proteins, intercellular and vascular adhesion molecules, and endogenous fibrinolysis inhibitors. This review discusses promising biomarkers and their role in the pathogenesis of hemorrhagic transformation, with a particular emphasis on their sensitivity, specificity, and the availability of threshold values.

Функциональная электрическая стимуляция при ходьбе в раннем восстановительном периоде ишемического инсульта

Multichannel functional electrical stimulation (MFES) is a promising method for rehabilitation of post-stroke patients aimed at restoring walking function at different periods after acute cerebrovascular accident. This review systematizes modern concepts of the use of MFES in patients with cerebral stroke, analyzing the technical parameters of stimulation, methodological approaches to the procedures and the clinical effectiveness of the method. Analysis of literary data demonstrates significant variability of MFES protocols: the stimulation frequency varies from 20 to 100 Hz, the duration of procedures is from 15 to 60 minutes, the course of treatment can last from 3 to 30 weeks. The main targets of the impact are four muscle groups of the lower extremities: the anterior tibialis muscle, plantar flexors, quadriceps femoris and hamstrings. Synchronization of stimulation with the gait cycle is carried out mainly by means of contact sensors, accelerometers and EMG signals, although modern developments include inertial systems and machine learning algorithms. This review presents a comprehensive analysis of the technical aspects of MPES from the standpoint of the stages of motor learning and individualization of stimulation parameters. Particular attention is paid to the integration of MPES with robotic devices, including exoskeletons, which represents a new direction in rehabilitation. The work identifies critical gaps in existing research related to the lack of uniform criteria for selecting stimulation parameters and the need for a differentiated approach depending on the type of motor disorders, the period of the disease and the patient's cognitive capabilities. The presented analysis substantiates the need to develop personalized MPES protocols and conduct large-scale studies to optimize stimulation parameters in the rehabilitation of post-stroke patients.

Introduction. The severity of endothelial destruction in patients with the new COVID-19 new coronavirus infection may be correlated with the risk of developing acute cerebrovascular accident (ACVA).Objective. To study the role of hemostasis system activation markers and vascular wall damage markers in the development of stroke in patients with the new coronavirus infection.Materials and methods. The study included 38 patients with the new coronavirus infection and ACVA and 40 patients with the new coronavirus infection without ACVA. All patients were tested for antibodies to β2-glycoprotein, antibodies to cardiolipin, plasminogen activator inhibitor type 1 (PAI-1), α2-antiplasmin, intercellular adhesion molecule type 1 (ICAM-1), von Willebrand factor, and homocysteine.Results. No statistically significant differences were found between the groups in terms of antiphospholipid antibody levels; however, increased antibodies to β2-glycoprotein relative to the reference interval were more frequent in the group without ACVA. Significant differences in PAI-1 levels were found between the group with ACVA and the comparison group (p < 0.001), with the PAI-1 concentration being 1.6 times higher in the comparison group. No significant differences were observed between the groups in terms of α2-antiplasmin, ICAM-1, and von Willebrand factor levels. Significant differences for homocysteine were found between the ACVA group and the comparison group (p < 0.001), with the concentration in the comparison group being 1.8 times higher.Conclusions. The development of acute cerebrovascular accident in patients with lower concentrations of homocysteine and PAI-1 may be explained by weaker compensatory mechanisms aimed at repairing of the vascular wall and harmonization of interaction of hemostasis system links, which eventually led to vascular wall damage.

Spasticity is one of the most common conditions in individuals with central nervous system damage and a significant contributor to the patient’s recovery. The processes indirectly contributing to this condition include the increased viscosity of hyaluronic acid due to paresis-associated changes in the circulation of extracellular matrix resulting in increased muscle rigidity. This is why spasticity may not be considered solely as a consequence of damage of the central nervous system. The review aims to verify the phenomenon of spasticity and study the possibility of its objective diagnosis. PubMed and eLibrary databases were used to search for literature. Analysis of available sources permits to abandon the widespread use of the term “spasticity” by replacing it with “deforming spastic paresis,” which will allow us to cover various pathophysiological attributes and variants of this condition, and, accordingly, reconsider both diagnostic and therapeutic approaches to it. Deforming spastic paresis may manifest with varying degrees of severity, in different movement phases, and different muscles. Despite the rapid development of instrumental methods of diagnosis, there are currently no uniform, general-purpose algorithms used to evaluate deforming spastic paresis. This is also true for the Modified Ashworth Scale and Modified Tardieu Scale used to quantify spasticity in clinical setting as they are reproduced only when the patient does not move, and do not directly evaluate the contribution of this phenomenon to the motor act. Methods involving robot-based test movements for verification appear to be most adequate, since they allow to standardize the method and make it more convenient for specialist assessment.

Functional electrical stimulation involves the use of electrical impulses to stimulate muscles during motor activity, particularly in patients with an acute cerebrovascular accident and are undergoing rehabilitation to regain their ability to walk. This study aimed to examine the existing literature on the use of functional electrical stimulation, focusing on the application methods and stimulation parameters. The authors analyzed the studies and determined scientifically validated parameters for stimulation and methods of applying functional electrical stimulation. This article provides a summary of key parameters such as frequency, waveform, amplitude, and duration of the electrical pulse and information on the placement of electrodes and synchronization of the pulses with movement, specifically with the gait cycle. Additionally, it covers aspects such as the timing of procedures and frequency and duration of treatment. The currently known aspects, advantages, and limitations of the method are discussed. Notably, several key parameters used in functional electrical stimulation have not been scientifically justified. The criteria for conducting functional electrical stimulation procedures and courses are unclear, and contraindications are reduced as the method evolves. Systems used for implementing functional electrical stimulation vary significantly in their capabilities for setting up work and synchronization with movement. Considering the importance of rapidly restoring motor functions and the positive impact of functional electrical stimulation on physical and psychological health of neurological patients, further investigation is required to determine optimal parameters for functional electrical stimulation and its application methodology.

In the article, the authors answered the following questions: How often do anxious patients occur in clinical practice? Why do most patients with anxiety see primary care physicians rather than a psychiatrist? What complaints and manifestations help to suspect anxiety in the patient? How can a non-psychiatrist identify and diagnose anxiety? How to manage a patient with diagnosed anxiety? Short-term and long-term outcomes/prognosis.

Acute cerebrovascular accident throughout the world remains the main cause of subsequent disability in persons who have suffered a stroke. One promising area is neuromuscular stimulation. Functional electrical stimulation is a subtype of neuromuscular stimulation in which stimulation promotes functional and goal-oriented movements in the individual. A course of functional electrical stimulation was administered while walking to a 74-year-old patient in the late recovery period of an ischemic stroke (the right middle cerebral artery). 14 procedures were performed lasting from 20 to 30 minutes. Before and after the functional electrical stimulation course, a clinical study and a study of the biomechanics of walking were conducted. The results obtained showed an improvement in clinical indicators, inconsistent changes in the time parameters of the step cycle, an increase in amplitudes in the hip and knee joints, as well as normalization of the function of the knee and ankle joints of the paretic side. Functional EMG research showed both an improvement in muscle activity and normalization of their activity profile, as well as processes of function restructuring that require further study. During functional electrical stimulation, there were no negative reactions from the patient or irritation of the skin at the locations of the electrodes. The method of functional electrical stimulation requires further study and reasonable application in this category of patients.

The incidence of neurological complications in COVID-19 can reach 8–10% of all cases of new coronavirus infection; acute cerebrovascular accidents (ACA) dominate in their structure, which cause significant social and economic costs due to the high mortality and disability rates in this group of patients. The main pathophysiological mechanism leading to the development of ischemic cerebrovascular accidents (ischemic stroke, transient ischemic attack) is the phenomenon of hypercoagulation, which, together with the systemic inflammatory response to the viral infection, leads to the formation of macro- and microthrombi and the development of ischemic disorders of cerebral circulation. The ischemic stroke associated with COVID-19 is characterized by the onset at a younger age, the predominance of cryptogenic and cardioembolic pathogenetic variants, a more frequent occlusion of large cerebral vessels and thus a more pronounced clinical picture of the disease. The reserves for reducing mortality and disability in patients with cerebrovascular disease, especially stroke, during the spread of COVID-19 lie both in the prevention, treatment and rehabilitation of COVID-19 in patients at high risk of developing cardiovascular diseases and in ensuring specialized medical care for this category of patients.

A patient with diabetes mellitus often sees a neurologist. The article addresses the questions: why does such a patient go to a neurologist and with what complaints, what does a neurologist see and how can he help a patient with diabetes? The authors of the article pay attention to the clinical diversity of neurological manifestations of diabetes mellitus, including insomnia. Identification of sleep disorders and subsequent correction can become the cornerstone not only in effective control of diabetes mellitus, but also in improving the patient’s quality of life.